OP Medical Coder
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Key skills for this role
About the Role
Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations. Assign accurate ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.
Key Skills for This Role
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Overview
- Ensures proper coding of documents in accordance with the regulator’ coding guidelines and regulations.
- Assign accurate **ICD-9, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes** for diagnoses and procedures based on clinical documentation.
- Validate that final diagnoses and operative procedures documented by physicians are complete, accurate, and compliant with coding standards.
- Abstract relevant clinical information from health records, including secondary diagnoses, complications, and co-morbid conditions.
- Review medical records for documentation consistency, completeness, and adequacy to ensure accurate representation of patient care.
- Compute and assign the appropriate **Diagnosis Related Group (DRG)** for all inpatient cases.
- Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians, including updates on new coding guidelines and regulatory changes.
- Review physician documentation to ensure appropriate **Evaluation and Management (E&M)** levels are assigned using the correct CPT codes.
- Ensure coding compliance with applicable **HAAD/DOH** coding guidelines, regulations, and organizational policies.
- Provide constructive feedback to physicians regarding coding discrepancies, documentation deficiencies, and missed coding opportunities.
- Stay current with the latest coding classifications, coding updates, and DOH/HAAD coding directives.
- Perform miscellaneous duties and special projects as assigned.
- Carry out any additional responsibilities assigned by the Head of Department (HOD) within the scope of the role.
- Occupational Safety & Health (OSH) and Infection Control Responsibilities
- Comply with all Occupational Safety & Health (OSH) and Infection Control policies, standards, and procedures.
- Perform duties in accordance with documented OSH policies, procedures, and assigned responsibilities.
- Be familiar with emergency response and evacuation procedures.
- Report OSH hazards, incidents, near misses, and unsafe conditions, and assist in risk assessments and incident investigations.
- Comply with hospital waste management policies and procedures.
- Attend mandatory OSH, Infection Control, safety awareness programs, and emergency/mock drills.
- Use appropriate Personal Protective Equipment (PPE) and follow all applicable safety protocols.
- A graduate of Bachelor's Degree in Allied Health Sciences or related areas with at least two (2) years of coding experience.
- Valid Certified Coding Associate (CCA) certification from the American Health Information Management Association (AHIMA) **or** Certified Professional Coder (CPC) certification from the American Academy of Professional Coders (AAPC).
- Computer Literacy, MS Office.
- Excellent command of oral and written English.
Performance Criteria
- Achievement of Core Objectives in line with the expectations of the Management and stakeholders.
- Ability to work constructively and interact professionally with others.
- Ability to coordinate multiple tasks, adjust to changing priorities, and work within deadlines.
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